Wiki Coding Wellness normal vs abnormal

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I have a question on diagnosis coding for wellness exams. On our encounter form, there are options for the doctor to circle certain commonly used diagnoses and the wellness, adult normal and wellness adult abnormal are among those options. This particular patient had an appointment and the doctor isn't billing solely for a well visit, she is using E&M code 99215, but among the diagnoses being coded is an abnormal wellness . When the nurse took the patient back, she documented the reason for the visit as an annual physical but the provider did not document anything related to that. She would need to state she did a wellness exam and that her findings were abnormal, right? Also, would she need to state what those abnormal findings are? As a coder, I don't believe we can make the determination between normal vs abnormal. I appreciate any input on this.
 
It does sound like the provider will need to add some additional documentation. If the components of a wellness exam are documented (review of vaccines, need for colonoscopy, mammogram, or other age appropriate preventive measures) then you should be ok on that front, if not ask for them to be. As far as adding the additional E&M the provider will need to document what specifically they addressed/found outside of the wellness exam that warrants another charge and based on that documentation you would use the diagnosis codes for those findings.
 
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